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Routine school medical inspection
1939
PUBLIC HEALTH
Routine School Medical Inspection S By HENRY HERD, M.A., M.B., D.P.H.,
School Medical Officer, City of Manchester ; AND G. E ST. CLAIR STOCK,rELY, M.B., B.CH.,
,School Medical Officer, City of Leeds.
Dr. HENRY HERD For a few years some of us, perhaps I should say a few of us, have been advocating sundry departures from the system of routine medical inspection which was instituted in 1907. I think that Dr. Cronk was the first to secure publication of an article on this subject in Public Health. t At the Sanitary Congress in 1935 Dr. Holden and I both spoke on this question and there was some discussion, but the idea was new and discussion did not get far. Several School Medical Officers have in their Annual Reports referred to the criticisms then made of routine medical inspection and have usually come down on the safe, conservative side, or have even advocated the institution of yet another routine medical inspection, as a method of meeting those criticisms. The Board of Education in its Annual Report for 1935 devoted a considerable space to an exposition of the views of both sides as expressed in M.O's reports and was not unsympathetic to the new idea but, as one would expect, non-committal. Dr. Auden in one of his Annual Reports expressed his opinion, and we must recall that it is the opinion of a man of long experience and of sound judgment, that " the time is ripe for a reconsideration of the whole scheme of medical inspection as laid down by the Board of Education, and for the advocacy of a tess rigid system than one which entails the medical examination of very large numbers of healthy children on the chance that some unknown defect may be discovered and subsequently treated." Even a critic of the new suggestions admitted that " the intervals between the examinations are too long and irregular." Dr. Auden in the same report pointed out that routine inspections other than those of entrants bring to light an exceedingly small number of defects whose existence is not already known or which could not be discovered at less cost by other means. Recently I made a survey of over 600 records of children who have had all three routine inspections, and was surprised to find to how great an extent Dr. Auden's statement is true. There were, of course, a considerable number of defective
visions but these, as I shall point out later, can be discovered otherwise. There were only three anaemias, four tonsil cases, five otorrhoeas (three already under treatment), about 18 nasal catarrhs (six under treatment), two deflected nasal septa, two tachycardias, four spinal curvatures (three recorded as very slight), and one rheumatic heart (already under treatment). The case for the defence of routine inspections naturally must base itself largely on the belief that one might miss much by any other method, but I must say these figures do not impress me with the discoveries made after the first routine medical inspection of entrants. May I say at the outset that in advocating some modifications of the system of routine medical inspection I am not suggesting that we are doing too much. I am pressing for more inspections rather than less. I contend that we are not, under the present system, giving adequate supervision to the children who really need it. Our routine medical inspections at three or four yearly intervals have become too much a search for defects, instead of what they ought to be, a supervision of the growth and development of the child as a child and not as a collection of defects, and we cannot adequately supervise growth at these long intervals. As a matter of fact, the system of routine medical inspection is dissolving itself away before our eyes. The new proposals are, in fact, already to a considerable degree being applied now.
1. Routine and Special Inspections
Compare, for example, the number of routine inspections with the number of special inspections. The proportion of special inspections to routine inspections has increased enormously. In my own area last year there were 32,000 routine inspections and 49,000 special inspections. Of the former group somewhere about 7,000 required treatment for the defects or diseases found. Recollect that special inspections are not merely those of children brought before the doctor while he is at the school but cases sent between inspection to clinics by parents, by teachers, by attendance officers, by nurses, and practically all of these cases so " specially " inspected suffer from some * Opening papers in a debate arranged by the School condition which requires attention. If 49,000 Medical Services Group, Society of Medical Officers of cases requiring attention can be found without Health, London, November 2nd, 1938. routine inspection, why cannot the remaining t Puhlic Health. (1935). 48, 253. 107
PUBLIC HEALTH 7,000 who are found at routine inspection ? The clinics and schools are becoming places of consultation to an increasing degree. Quite a large proportion of the special cases are stethoscope cases, which have apparently revealed themselves as needing attention. Tonsils and spinal curvatures also figure largely.
2. Heights and Weights There is the matter of heights and weights. Let us suppose that you take these at each routine medical inspection. Of what significance are they ? You do not need to be told that although a child is considerably below the anthropometrical average, either in height or weight, that fact may be of no moment whatever. Height probably is largely a matter of heredity: weight is perhaps more affected by environmental conditions and therefore perhaps claims some consideration, but no one can contend that the measurement of height and weight at four-yearly intervals is adequate for a study in these respects of individual children. The London County Council has in this matter recognised the futility of routine medical inspection and has instituted a system of six-monthly measurements, an example which it is to be hoped will be followed by other authorities, although it involves considerable initial expense. I do not claim that these measurements are ideal as determinants of adequate growth but other methods are too elaborate, involve considerable calculation and even then are still so uncertain in result that we must be content for the present. A child who shows abnormality of growth can then become a subject for special examination.
3. Defective Vision Consider defective vision. In the case of entrants the Board of Education does not demand an eye test : there are, of course, devices by means of which a card test may be possible even t h e n - sufficiently accurate to determine whether a dark room test is desirable. But that is not the point in question now. The Board of Education has in this matter virtually superseded routine inspection by its demand that every case found to have a defect on the card test should be submitted to re-examination every twelve months. That in itself is a confession that routine inspection every four years in respect of defective vision is valueless. But in any case, if you reply to me that there will be children who at eight (say) can see e/6 who at twelve are found to have bad sight, I say why wait four years to discover it. Why not test every child once a year ?
4. Deaf and Partially Deaf Children When I speak of partially deaf children I am not using these words in a technical sense but to cover 108
JANUARY all cases that have difficulty in hearing in one or both ears. Here I think is to be found the strongest indictment of routine medical inspection for it has in its 30 years failed to discover large numbers of these children. Partial deafness unless very marked is a most elusive entity: mental defect has not uncommonly been diagnosed when deafness was the real trouble, and teachers in contact with children every day for years will fail to notice the lesser and not only the lesser degrees of deafness, even though they are interfering with the child's progress. Voice tests, watch tests, and the forced whisper have all failed us and salvation has come through the gramophone audiometer, an instrument which certainly cannot and should not be applied as part of routine medical inspection. I am only too aware of the fallacies of its findings, but they are fallacies which can be got over. Already authorities who have put it into use have found thousands of cases requiring attention of nasal and aural catarrh, conditions readily amenable to certain forms of treatment, particularly diastolisation or some other method of nasal hygiene.
5. Nutrition Then there is the vexed subject of nutrition. I suppose there must be ver~ few medical officers who consider that nutrition can be adequately assessed by a brief general survey of the child, or that even if you feel justified in saying that a child's nutrition is sub-normal you can go on to say he is not being properly fed. But while I believe it is impossible to make delicate diagnoses of children in this respect and say, e.g., definitely whether any one child is excellent or normal, I do think the really malnourished child can as a rule be discovered, and, if so, why only once in four years ? Should we not always be looking for these children ? And curiously enough here also the Board of Education has taken the step of asking for nutrition surveys of all children at each visit of the doctor to the school, and in so doing has (unconsciously, I believe) hammered another nail in the coffin of routine medical inspection.
Suggestions for Revision of the Present System What, then, is suggested to replace the present system ? 1. First of all, the routine inspection of all entrants should remain as at present. This seems unavoidable and indeed desirable so long as there is no adequate supervisionof children from two to five who are not in a school. One must also, I think, agree to a complete inspection of all leavers. This seems imperative in view of the form which the Board requires us to fill dealing with fitness or unfitness for various types of employment. My own opinion, however,
1939 is that this should not be filled up so early as at twelve years; as I envisage it, a doctor should visit a school once every term, and the " leaver exam." may therefore quite well be deferred until a later date than is the case on the present arrangements. And even then, if there has been close supervision of children showing defects or unsatisfactory growth during the years elapsing since entrance, any very detailed examination of such children should not be necessary. 2. For the period between the entrant and the leaving examination I suggest a visit once per term, i.e., three in the year by the doctor. Apart from his visit there are, however, certain tests which can be carried out independently. (a) Regular six-monthly measuring and weighing--perhaps three-monthly in infants. This, as already said, is now done in London and a graph record of each child is kept. These should provide the doctor with some material - - f o r over rapid growth in height or too slow growth in weight would both call for special examination of or enquiry regarding the child. Such records ought in time not merely to give us averages, but what is more important, give some evidence as to types of growth of which it would seem that there are several varieties. (b) Vision of every child should be tested yearly by the nurses. At the present time we are required to do a yearly test--and if necessary, refraction--of all found to have defective vision. In areas where clinics are near, these retests can readily be done there, though the school may be more convenient, but in rural areas the testing would more conveniently be done at school. (c) Gramophone audiometer tests can only be possible at longer intervals unless one is to have a large supply of the instrument, which would involve considerable expense. At present in my own area two nurses have been trained to this work and results are submitted to the School Aurist who personally sees all cases defective beyond a certain degree, at the nearest clinic. This is the only adequate method of dealing with this matter of children suffering from deafness of differing degrees. Routine medical inspection has completely failed here. At the visits of the Medical Officer to the schools le would see : - (1) All cases which at a former visit he had ound to have any defect or disease or lack of dequate growth. (2) Children whose height and weight record is Lot satisfactory. (3) Children who have been absent from school Dr long periods or frequent intermittent periods,
PUBLIC HEALTH or who have had a serious illness since the last visit. Dr. Cronk has on this point shown the value of reference to the school register which he described as a " most important medical document." (4) Children referred either by teachers or parents on account of a variety of conditions: children who show signs of fatigue easily, who are pale, who are breathless (say in P.T.), or otherwise seem to fail in alertness. (5) The doctor himself should survey the children either in their classes or they can be paraded before him or he can observe them in P.T. lesson or at play. In this way he ,nay discover not only the state of nutrition, as at present prescribed, but he can find others : pale children, stunted children, children with bad postures or gait, squints if not already discovered, children with minor ailments, children with adenoid symptoms. Far too little is done in our work in the way of shrewd observation. I have in my mind a Residential Open-Air School for which I am responsible. A local practitioner attends to the children when they are ill and independently visits the school once a week to supervise the children, there being an understanding that he shall see each child at least once monthly. His method is to go down to the school, look over the children, watch them at play, pick out the children who loll and flag, or stand aside leaning against a post, look at posture and gait-he only applies a stethoscope when the child's medical record or some obvious symptom reported to him, e.g., a cough makes it necessary. We are far too much tied to our stethoscopes; let us use our eyes more. If you ask me how are tonsils going to be discovered, and how such conditions as spinal curvature. Is there any reason why a doctor visiting in this way should not at certain of his visits make a point of inspecting throats and noses or even look at spines, though the latter do not seem even at routine inspection to be discovered in any numbers until the twelve year old inspection, and they do seem to be brought forward even on our present arrangements at special inspections. I have not said anything of the common criticism of routine medical inspection that it entails a full examination of so many children who are normal. There is, of course, much waste of time, which might be more usefully employed, in that way. But I sometimes feel, as already suggested, that a doctor engaged day to day in routine medical inspection and carrying out the same examination in every case is disposed in his meticulous search for organic defects to neglect a general survey of the child as a growing organism. It seems to me also that this revised method of medical inspection would make the individual 1(}9
PUBLIC
HEALTH
S.M.O. or A.S.M.O. a much more integral part of the school than he is now. There is one further suggestion I should like to make and that is that at some of his visits, he should give a short talk to groups of older children on some aspect of health and hygiene. I know that this suggestion is in certain quarters regarded as unorthodox, if not objectionable. But surely if a policeman can be imported into a school to talk on safety, there is no inappropriateness in the appearance of a doctor and particularly a school doctor who, after all, is part of the organisation, to talk on health.
Dr. G. E. ST. CLAIR STOCKWELL I wish at the outset to state that in my view it is desirable that there should rather be more routine inspections than fewer and that any attempts to abolish any of them would meet with much hostility from parents. One thing I detest is the word " routine." Its implication alone is bad. What is really required is a thorough examination of every child as often as possible--every two years for choice, with a yearly reinvestigation at least of every child with any defect. The L.C.C. set up a committee of their own to go into the whole question of medical inspection and unanimously approved the addition of another age group. The report contained many valuable points, including the following :-(1) Medical inspection is designed to detect children who are in any way disabled. Its object is to detect disablement, not to diagnose it. It should go no further than to establish the fact that abnormalities are present or reasonably suspected and to decide what further examination, with or without a view to treatment, is necessary and that such further examinations are available at an appropriate time in an appropriate place by an appropriate person. The time i s not that of medical inspection ; the place is not school ; the person may or may not be the medical inspector. (2) The time of medical inspection must be short, because what is sought can be discovered more readily in a short time than in a long examination. Apparatus should be reduced to a minimum because, though a frightened child may be examined, he cannot be inspected. I cannot see how such ideals can be achieved without repeated inspections. Further, amongst the duties laid upon authorities by the Education Act of 1921 we are told :-" . . . To make or otherwise to secure such adequate and suitable arrangements for attending to the health and physical condition of the children and to provide for their medical inspection on such occasions as the Ministry of Health may direct." 110
JANUARY How such arrangements can be made without constant medical inspection passes my comprehension. It was urged by Dr. Cronk and other advocates of the reduction of medical inspection that the three examinations merely gave three cross sections of a child's life and not a longitudinal one. My reply is that such a result is the fault of execution and not of the intention of medical inspection. One sees often several cards for one child--that is, many inspections without any correlation and without any reinspection. The ideal must be to have a complete medical history on one.card, on which all relevant knowledge from every possible source should appear. This cannot happen unless the child is under constant review. It is possible, for it is done with us and has been for many years. Even objectors to routine inspection admit that a leaving examination is necessary so as to enable us to supply information to National Health practitioners, but I have urged for years that school medical records should be sent to the Commissioners. We keep ours for ten years and then they are burnt--what a waste! No--there must be additions to, not subtractions from, the number of routine inspections and every child kept under frequent review until all disablement is clear. Think of the large number of children with many minor defects, in themselves alone not severe, but when they are summed up disclose quite severe disability. A child with a minor degree of myopia, with slight loss of hearing, with a slight degree of infantile paralysis and an I.Q. of 90 per cent. must be seen repeatedly and not on separate cards every time. We are told that we have to do nutrition surveys, and so forth. I still say that routine inspection (much as I hate the word " routine ") will help us even in this and should be the first charge on the School Medical Service.
TIlE Annual Congress of the Royal Institute of Public Health and Hygiene will be held in Hastings from Tuesday, May 28rd, to Saturday, May 27th, 1989. The Inaugural Meeting will be held in the afternoon of Tuesday, May 23rd, and the following subjects will be discussed in the various sections : " State Medicine and Industrial Hygiene" ; "Women and Children and the Public Health " ; " Tuberculosis " ; " Rheumatism and Allied Diseases " ; " Nutrition and Physical Education ". Full details of delegates fees, etc., may be obtained from the Secretary, 28, Portland Place, London, W.1.
PUBLIC HEALTH
Routine School Medical Inspection S By HENRY HERD, M.A., M.B., D.P.H.,
School Medical Officer, City of Manchester ; AND G. E ST. CLAIR STOCK,rELY, M.B., B.CH.,
,School Medical Officer, City of Leeds.
Dr. HENRY HERD For a few years some of us, perhaps I should say a few of us, have been advocating sundry departures from the system of routine medical inspection which was instituted in 1907. I think that Dr. Cronk was the first to secure publication of an article on this subject in Public Health. t At the Sanitary Congress in 1935 Dr. Holden and I both spoke on this question and there was some discussion, but the idea was new and discussion did not get far. Several School Medical Officers have in their Annual Reports referred to the criticisms then made of routine medical inspection and have usually come down on the safe, conservative side, or have even advocated the institution of yet another routine medical inspection, as a method of meeting those criticisms. The Board of Education in its Annual Report for 1935 devoted a considerable space to an exposition of the views of both sides as expressed in M.O's reports and was not unsympathetic to the new idea but, as one would expect, non-committal. Dr. Auden in one of his Annual Reports expressed his opinion, and we must recall that it is the opinion of a man of long experience and of sound judgment, that " the time is ripe for a reconsideration of the whole scheme of medical inspection as laid down by the Board of Education, and for the advocacy of a tess rigid system than one which entails the medical examination of very large numbers of healthy children on the chance that some unknown defect may be discovered and subsequently treated." Even a critic of the new suggestions admitted that " the intervals between the examinations are too long and irregular." Dr. Auden in the same report pointed out that routine inspections other than those of entrants bring to light an exceedingly small number of defects whose existence is not already known or which could not be discovered at less cost by other means. Recently I made a survey of over 600 records of children who have had all three routine inspections, and was surprised to find to how great an extent Dr. Auden's statement is true. There were, of course, a considerable number of defective
visions but these, as I shall point out later, can be discovered otherwise. There were only three anaemias, four tonsil cases, five otorrhoeas (three already under treatment), about 18 nasal catarrhs (six under treatment), two deflected nasal septa, two tachycardias, four spinal curvatures (three recorded as very slight), and one rheumatic heart (already under treatment). The case for the defence of routine inspections naturally must base itself largely on the belief that one might miss much by any other method, but I must say these figures do not impress me with the discoveries made after the first routine medical inspection of entrants. May I say at the outset that in advocating some modifications of the system of routine medical inspection I am not suggesting that we are doing too much. I am pressing for more inspections rather than less. I contend that we are not, under the present system, giving adequate supervision to the children who really need it. Our routine medical inspections at three or four yearly intervals have become too much a search for defects, instead of what they ought to be, a supervision of the growth and development of the child as a child and not as a collection of defects, and we cannot adequately supervise growth at these long intervals. As a matter of fact, the system of routine medical inspection is dissolving itself away before our eyes. The new proposals are, in fact, already to a considerable degree being applied now.
1. Routine and Special Inspections
Compare, for example, the number of routine inspections with the number of special inspections. The proportion of special inspections to routine inspections has increased enormously. In my own area last year there were 32,000 routine inspections and 49,000 special inspections. Of the former group somewhere about 7,000 required treatment for the defects or diseases found. Recollect that special inspections are not merely those of children brought before the doctor while he is at the school but cases sent between inspection to clinics by parents, by teachers, by attendance officers, by nurses, and practically all of these cases so " specially " inspected suffer from some * Opening papers in a debate arranged by the School condition which requires attention. If 49,000 Medical Services Group, Society of Medical Officers of cases requiring attention can be found without Health, London, November 2nd, 1938. routine inspection, why cannot the remaining t Puhlic Health. (1935). 48, 253. 107
PUBLIC HEALTH 7,000 who are found at routine inspection ? The clinics and schools are becoming places of consultation to an increasing degree. Quite a large proportion of the special cases are stethoscope cases, which have apparently revealed themselves as needing attention. Tonsils and spinal curvatures also figure largely.
2. Heights and Weights There is the matter of heights and weights. Let us suppose that you take these at each routine medical inspection. Of what significance are they ? You do not need to be told that although a child is considerably below the anthropometrical average, either in height or weight, that fact may be of no moment whatever. Height probably is largely a matter of heredity: weight is perhaps more affected by environmental conditions and therefore perhaps claims some consideration, but no one can contend that the measurement of height and weight at four-yearly intervals is adequate for a study in these respects of individual children. The London County Council has in this matter recognised the futility of routine medical inspection and has instituted a system of six-monthly measurements, an example which it is to be hoped will be followed by other authorities, although it involves considerable initial expense. I do not claim that these measurements are ideal as determinants of adequate growth but other methods are too elaborate, involve considerable calculation and even then are still so uncertain in result that we must be content for the present. A child who shows abnormality of growth can then become a subject for special examination.
3. Defective Vision Consider defective vision. In the case of entrants the Board of Education does not demand an eye test : there are, of course, devices by means of which a card test may be possible even t h e n - sufficiently accurate to determine whether a dark room test is desirable. But that is not the point in question now. The Board of Education has in this matter virtually superseded routine inspection by its demand that every case found to have a defect on the card test should be submitted to re-examination every twelve months. That in itself is a confession that routine inspection every four years in respect of defective vision is valueless. But in any case, if you reply to me that there will be children who at eight (say) can see e/6 who at twelve are found to have bad sight, I say why wait four years to discover it. Why not test every child once a year ?
4. Deaf and Partially Deaf Children When I speak of partially deaf children I am not using these words in a technical sense but to cover 108
JANUARY all cases that have difficulty in hearing in one or both ears. Here I think is to be found the strongest indictment of routine medical inspection for it has in its 30 years failed to discover large numbers of these children. Partial deafness unless very marked is a most elusive entity: mental defect has not uncommonly been diagnosed when deafness was the real trouble, and teachers in contact with children every day for years will fail to notice the lesser and not only the lesser degrees of deafness, even though they are interfering with the child's progress. Voice tests, watch tests, and the forced whisper have all failed us and salvation has come through the gramophone audiometer, an instrument which certainly cannot and should not be applied as part of routine medical inspection. I am only too aware of the fallacies of its findings, but they are fallacies which can be got over. Already authorities who have put it into use have found thousands of cases requiring attention of nasal and aural catarrh, conditions readily amenable to certain forms of treatment, particularly diastolisation or some other method of nasal hygiene.
5. Nutrition Then there is the vexed subject of nutrition. I suppose there must be ver~ few medical officers who consider that nutrition can be adequately assessed by a brief general survey of the child, or that even if you feel justified in saying that a child's nutrition is sub-normal you can go on to say he is not being properly fed. But while I believe it is impossible to make delicate diagnoses of children in this respect and say, e.g., definitely whether any one child is excellent or normal, I do think the really malnourished child can as a rule be discovered, and, if so, why only once in four years ? Should we not always be looking for these children ? And curiously enough here also the Board of Education has taken the step of asking for nutrition surveys of all children at each visit of the doctor to the school, and in so doing has (unconsciously, I believe) hammered another nail in the coffin of routine medical inspection.
Suggestions for Revision of the Present System What, then, is suggested to replace the present system ? 1. First of all, the routine inspection of all entrants should remain as at present. This seems unavoidable and indeed desirable so long as there is no adequate supervisionof children from two to five who are not in a school. One must also, I think, agree to a complete inspection of all leavers. This seems imperative in view of the form which the Board requires us to fill dealing with fitness or unfitness for various types of employment. My own opinion, however,
1939 is that this should not be filled up so early as at twelve years; as I envisage it, a doctor should visit a school once every term, and the " leaver exam." may therefore quite well be deferred until a later date than is the case on the present arrangements. And even then, if there has been close supervision of children showing defects or unsatisfactory growth during the years elapsing since entrance, any very detailed examination of such children should not be necessary. 2. For the period between the entrant and the leaving examination I suggest a visit once per term, i.e., three in the year by the doctor. Apart from his visit there are, however, certain tests which can be carried out independently. (a) Regular six-monthly measuring and weighing--perhaps three-monthly in infants. This, as already said, is now done in London and a graph record of each child is kept. These should provide the doctor with some material - - f o r over rapid growth in height or too slow growth in weight would both call for special examination of or enquiry regarding the child. Such records ought in time not merely to give us averages, but what is more important, give some evidence as to types of growth of which it would seem that there are several varieties. (b) Vision of every child should be tested yearly by the nurses. At the present time we are required to do a yearly test--and if necessary, refraction--of all found to have defective vision. In areas where clinics are near, these retests can readily be done there, though the school may be more convenient, but in rural areas the testing would more conveniently be done at school. (c) Gramophone audiometer tests can only be possible at longer intervals unless one is to have a large supply of the instrument, which would involve considerable expense. At present in my own area two nurses have been trained to this work and results are submitted to the School Aurist who personally sees all cases defective beyond a certain degree, at the nearest clinic. This is the only adequate method of dealing with this matter of children suffering from deafness of differing degrees. Routine medical inspection has completely failed here. At the visits of the Medical Officer to the schools le would see : - (1) All cases which at a former visit he had ound to have any defect or disease or lack of dequate growth. (2) Children whose height and weight record is Lot satisfactory. (3) Children who have been absent from school Dr long periods or frequent intermittent periods,
PUBLIC HEALTH or who have had a serious illness since the last visit. Dr. Cronk has on this point shown the value of reference to the school register which he described as a " most important medical document." (4) Children referred either by teachers or parents on account of a variety of conditions: children who show signs of fatigue easily, who are pale, who are breathless (say in P.T.), or otherwise seem to fail in alertness. (5) The doctor himself should survey the children either in their classes or they can be paraded before him or he can observe them in P.T. lesson or at play. In this way he ,nay discover not only the state of nutrition, as at present prescribed, but he can find others : pale children, stunted children, children with bad postures or gait, squints if not already discovered, children with minor ailments, children with adenoid symptoms. Far too little is done in our work in the way of shrewd observation. I have in my mind a Residential Open-Air School for which I am responsible. A local practitioner attends to the children when they are ill and independently visits the school once a week to supervise the children, there being an understanding that he shall see each child at least once monthly. His method is to go down to the school, look over the children, watch them at play, pick out the children who loll and flag, or stand aside leaning against a post, look at posture and gait-he only applies a stethoscope when the child's medical record or some obvious symptom reported to him, e.g., a cough makes it necessary. We are far too much tied to our stethoscopes; let us use our eyes more. If you ask me how are tonsils going to be discovered, and how such conditions as spinal curvature. Is there any reason why a doctor visiting in this way should not at certain of his visits make a point of inspecting throats and noses or even look at spines, though the latter do not seem even at routine inspection to be discovered in any numbers until the twelve year old inspection, and they do seem to be brought forward even on our present arrangements at special inspections. I have not said anything of the common criticism of routine medical inspection that it entails a full examination of so many children who are normal. There is, of course, much waste of time, which might be more usefully employed, in that way. But I sometimes feel, as already suggested, that a doctor engaged day to day in routine medical inspection and carrying out the same examination in every case is disposed in his meticulous search for organic defects to neglect a general survey of the child as a growing organism. It seems to me also that this revised method of medical inspection would make the individual 1(}9
PUBLIC
HEALTH
S.M.O. or A.S.M.O. a much more integral part of the school than he is now. There is one further suggestion I should like to make and that is that at some of his visits, he should give a short talk to groups of older children on some aspect of health and hygiene. I know that this suggestion is in certain quarters regarded as unorthodox, if not objectionable. But surely if a policeman can be imported into a school to talk on safety, there is no inappropriateness in the appearance of a doctor and particularly a school doctor who, after all, is part of the organisation, to talk on health.
Dr. G. E. ST. CLAIR STOCKWELL I wish at the outset to state that in my view it is desirable that there should rather be more routine inspections than fewer and that any attempts to abolish any of them would meet with much hostility from parents. One thing I detest is the word " routine." Its implication alone is bad. What is really required is a thorough examination of every child as often as possible--every two years for choice, with a yearly reinvestigation at least of every child with any defect. The L.C.C. set up a committee of their own to go into the whole question of medical inspection and unanimously approved the addition of another age group. The report contained many valuable points, including the following :-(1) Medical inspection is designed to detect children who are in any way disabled. Its object is to detect disablement, not to diagnose it. It should go no further than to establish the fact that abnormalities are present or reasonably suspected and to decide what further examination, with or without a view to treatment, is necessary and that such further examinations are available at an appropriate time in an appropriate place by an appropriate person. The time i s not that of medical inspection ; the place is not school ; the person may or may not be the medical inspector. (2) The time of medical inspection must be short, because what is sought can be discovered more readily in a short time than in a long examination. Apparatus should be reduced to a minimum because, though a frightened child may be examined, he cannot be inspected. I cannot see how such ideals can be achieved without repeated inspections. Further, amongst the duties laid upon authorities by the Education Act of 1921 we are told :-" . . . To make or otherwise to secure such adequate and suitable arrangements for attending to the health and physical condition of the children and to provide for their medical inspection on such occasions as the Ministry of Health may direct." 110
JANUARY How such arrangements can be made without constant medical inspection passes my comprehension. It was urged by Dr. Cronk and other advocates of the reduction of medical inspection that the three examinations merely gave three cross sections of a child's life and not a longitudinal one. My reply is that such a result is the fault of execution and not of the intention of medical inspection. One sees often several cards for one child--that is, many inspections without any correlation and without any reinspection. The ideal must be to have a complete medical history on one.card, on which all relevant knowledge from every possible source should appear. This cannot happen unless the child is under constant review. It is possible, for it is done with us and has been for many years. Even objectors to routine inspection admit that a leaving examination is necessary so as to enable us to supply information to National Health practitioners, but I have urged for years that school medical records should be sent to the Commissioners. We keep ours for ten years and then they are burnt--what a waste! No--there must be additions to, not subtractions from, the number of routine inspections and every child kept under frequent review until all disablement is clear. Think of the large number of children with many minor defects, in themselves alone not severe, but when they are summed up disclose quite severe disability. A child with a minor degree of myopia, with slight loss of hearing, with a slight degree of infantile paralysis and an I.Q. of 90 per cent. must be seen repeatedly and not on separate cards every time. We are told that we have to do nutrition surveys, and so forth. I still say that routine inspection (much as I hate the word " routine ") will help us even in this and should be the first charge on the School Medical Service.
TIlE Annual Congress of the Royal Institute of Public Health and Hygiene will be held in Hastings from Tuesday, May 28rd, to Saturday, May 27th, 1989. The Inaugural Meeting will be held in the afternoon of Tuesday, May 23rd, and the following subjects will be discussed in the various sections : " State Medicine and Industrial Hygiene" ; "Women and Children and the Public Health " ; " Tuberculosis " ; " Rheumatism and Allied Diseases " ; " Nutrition and Physical Education ". Full details of delegates fees, etc., may be obtained from the Secretary, 28, Portland Place, London, W.1.